Dr. Michaud on NH Chronicle November 26th!

Posted on November 25, 2014.

Complex regional pain syndrome awareness tomorrow night (Nov 26th) at 7pm on NH Chronicle WMUR ... Read More

Food Drive for the NH Food Bank!

Posted on November 13, 2014.

We are hosting our 4th Annual Food Drive! New Hampshire Orthopaedic Center is participating again ... Read More

Youth Sports Safety Week

Posted on October 28, 2014.
New Hampshire Orthopaedic Center

Hike Your Way to Health – By: William P. Rix, MD

Posted on October 14, 2014.

Orthopaedic surgeons strongly recommend a regular exercise program to promote musculoskeletal health. An ideal exercise is one that is aerobic, strengthens the core as well as all four extremities, improves balance, is low impact, reasonably safe, and is able to be performed throughout life.

The sport of hiking fulfills all the above criteria. It is a “controlled” sport where the chance of injury is low. Hiking is classified as a “moderate dynamic loading” activity. This is in contrast to the high impact, high intensity sports such as hockey, football and basketball. There is now scientific evidence that moderate loading sports are beneficial and protective to the articular cartilage that lines all our joints. This is important because arthritis is a degenerative disease of articular cartilage. Moderate loading sports such as hiking can potentially protect joints against arthritis.

The startup costs of hiking are modest, and it can be a social (group hiking) or solitary activity. In New Hampshire we are blessed with endless hiking trails on mountains from 2000 to 6000 feet. The introductory hiker should start small and increase the intensity and duration of the hikes as he or she becomes more fit. I strongly recommend hiking with two walking poles as it broadens one’s base of support, and exercises all four extremities. The basic equipment includes sturdy boots, a comfortable daypack, inclement weather clothing, a map, compass, food and water. For a complete list of items recommended for a day hike, one should consult hiking websites such as The Appalachian Mountain Club.

The attractiveness of hiking is in its variability. By varying the length (miles), difficulty (roughness of the terrain) and steepness (elevation gain/distance) on successive outings, one can hike to get in shape, rehabilitate from an injury or maintain a desired level of fitness. As a bonus, the endpoint of a day’s outing is often a breathtaking view, a waterfall, or a mountain lake. I would recommend keeping a log of your successive hikes as you monitor your improved fitness or rehabilitation.

The following is a small sampling of progressively more demanding day hikes (Introductory 1 through 4; Moderate 5 through 8; Challenging 9 through 12):

Trail Mountain Round Trip



Gain (ft)

1. Mount Pemigewasset Trail Mount Pemigewasset 3 miles 1100
2. Barlow Trail Mount Kearsarge(South) 3.6 miles 1100
3. Andrew Brook Trail Mount Sunapee(L.Solitude) 4 miles 1100
4. Willard Trail Mount Willard 3.5 miles 1000
5. Morgan and Percival Trail Mount Morgan and Percival 5 miles 1500
6. Tecumseh Trail Tecumseh Trail 5 miles 2200
7. Welch-Dickey Trail Welch and Dickey 5 miles 1800
8. Sandwich Mountain Trail Jennings Peak 6 miles 1900
9. Airline Trail Mount Adams 9 miles 4500
10. Franconia Ridge Trail Loop Mount Lafayette, Lincoln & Haystack 8 miles 3500
11. Beaver Brook Trail Mount Moosilauke 8 miles 3100
12. Tuckerman Ravine Trail Mount Washington 8.5 miles 4250















For more trail recommendations, consult manuals like the AMC White Mountain Guide, the Falcon Series on Hiking NH, or 50 Hikes in New Hampshire by Daniel Doan.

And the next time someone snaps “Hey, why don’t you take a hike?”, say “Thanks for the good advice, I’ll do it”.

Joint Replacement in Tanzania

Posted on August 28, 2014.

WOGO Group Photo

Joint Replacement in Tanzania

By: Kathleen A. Hogan, MD

In June, I participated in an amazing trip to Arusha, Tanzania with a group of five female joint surgeons and 45 additional health care professionals including physician assistants, physical therapists, nurses, anesthesiologists, and medical doctors. Our group is called WOGO – Women Orthopaedist Global Outreach. In four days, we operated on 32 patients and replaced 44 severely arthritic knees. In addition we offered an educational seminar to local physicians and nurses and had Tanzanian orthopaedic residents scrub with us in the operating room. We traveled to an orphanage and to a rehab hospital for children recovering from surgery where we put shoes on children’s feet and smiles on their faces. This trip was the hardest thing I have ever done, but also the most rewarding.

Most patients in Tanzania cannot afford to have joint replacement surgery as they are responsible for the cost of the implants. The average yearly income is only $500, and sixty eight percent of the population is below the international poverty rate living on less than $1.25/day. Even for the upper class, joint replacements are often not financially feasible.

The Arusha Lutheran Medical Center (ALMC) is a 125 bed hospital with four operating rooms. Access to health care is often limited in Tanzania especially in rural areas; there is only 1 physician and 2 nurses for every 10,000 people. ALMC was clean but much of the equipment was old. For example, we used duck tape to secure one operating room table to the floor as its locking mechanism no longer worked. The lights frequently went out and it would take a few minutes before the generator would restore power.

On our first day, we saw over 54 patients in clinic who had been pre-screened for surgery. Most took anti-inflammatory medications, however very few had received other treatments such as physical therapy or injections. Most patients had very severe arthritis with fixed deformities. Later in the day, we presented each patient and their X-rays and determined if they were good candidates for surgery.

That afternoon we started doing knee replacements. We did three cases that evening and spent the next three days in the OR. It was an intense and often overwhelming first few days, with no opportunity to adjust to the seven hour time difference!

For anesthesia during surgery patients received both a femoral and spinal nerve block, and after surgery patients received only Tylenol and tramadol for pain. There were no narcotic pain medications such as Oxycodone or Percocet available, yet every patient got out of bed the day after surgery and walked in the hallway with our physical therapists. The hospital floor did not have an area large enough for physical therapy so our patients went outside to the large balcony for their therapy

Our nurses were helped by the local nurses at the hospital who were eager to learn from us. The staff was very helpful and our patients received excellent care. For example, if we needed labs drawn someone would come and draw the blood and bring the results back up to the floor within 15 minutes, much faster than in our hospitals here! There were no computers or electronic medical records so patient charts were on paper and X-rays on film. Patients’ families were very involved and often a small crowd would follow a patient as they walked in the hallway.

How will our patients do after surgery? We partner with hospitals where there are orthopedic surgeons who are supportive of WOGO and will provide follow up care as needed, and can contact us with any concerns.

Tanzania is beautiful but also very rural and very poor. Young children herd cattle and goats in the fields and on the side of the road, women walk with baskets on their heads and with children strapped to their backs. Everything is dusty and dirty and outside the city many roads are unpaved. Only 45% of homes have electricity. Conditions for women are particularly dire. Young girls are vulnerable to being kidnapped and sold as “house slaves”. Forty percent of women have been victims of physical violence and one in five women are married to a man with more than one wife. Women are responsible for all the housework, food preparation, and childcare.

One of the most moving experiences I had on this trip was visiting the Plaster House.   This is a home for children to rehabilitate after surgery. Many children in Tanzania have severe bone deformities; cleft palate, spina bifida, club feet, and cerebral palsy are also common. The Plaster House is a clean, safe place where children can recover for three to six months after surgery. The parents often do not visit during this time. The children are fed, cared for, and educated. For some, these may be the best living conditions they ever experience. We spent time coloring with these children and distributed shoes in partnership with Soles4Souls. These kids were so excited to have shoes. It is amazing how much joy I saw on those kids faces. It brings tears to my eyes when I think about it.

The following day we traveled almost 2 hours into the countryside to an orphanage and school. People from the village lined up for shoes. We set up soccer nets that we had brought along with our cargo of medical supplies as a gift for the children. I had the opportunity to walk to a small village where I saw both incredible poverty and beauty. The homes were smaller then my living room for as many as 10 people. There was no running water or electricity or toilets. Children were in tattered clothes and without shoes. The older kids were taking care of the younger ones; there were very few adults. However, when you looked around there was a wildness and a beauty to the countryside that is difficult to describe.

During the 10 days I was in Africa I met so many incredible people; my patients, my team members, and the many people who are doing so much good in such an impoverished country. At times the problems confronting a third world country seem overwhelming, but I do believe that you can make a difference one person at a time.


These trips are very expensive, yet do so much good. We will be planning our next one soon! Please consider donating to WOGO – 314 S. South Street, Mount Airy NC 27030

Ulnar Collateral Ligament Injuries of the Elbow

Posted on August 26, 2014.

Ulnar Collateral Ligament Injuries of the Elbow

By: Daniel P. Bouvier, MD


Elbow injuries in adolescent athletes have gained quite a bit of attention over the last decade with increased sports participation, physician awareness, and media attention. There has also been an alarming rate of increased surgical procedure performed in younger athletes in that timeframe.

What is it?

The ulnar collateral ligament is a 3 part ligament on the inside part of the elbow that connects the upper arm to one of the forearm bones (ulna). It provides stability to the hinge joint of the elbow resisting the outward directed stress placed on the elbow during the throwing motion. Pitching a baseball has been shown to generate forces at the elbow very close to the ultimate strength of the ulnar collateral ligament, which over time and repetition, can lead to failure of the ligament.


Some patients may report an actual “pop” felt while throwing, which would represent an acute (sudden) injury to the ligament. Many others will describe a vague pain, consistent in its location and during the late cocking and early acceleration phase of the throwing motion. This is more consistent with a chronic attenuation (thinning) of the ligament. Some may also describe some nerve symptoms, such as numbness or tingling into the fingertips (from the ulnar or “funny bone)nerve). It’s important to also know the patients history of position played, frequency of play, number of pitches, prior treatments and offseason regimen.

Risk Factors

Four potential risk factors for elbow (and shoulder) injuries in youth baseball have been identified: Number of pitches thrown (in a game, season, and year), type of pitches, pitching mechanics, and physical condition. The number of pitches thrown seems to be the most important. Recent studies have suggested that the curveball may not be any more dangerous than any of the other pitches, and that the change up is likely the safest. Pitch counts were mandated by Little League Baseball many years ago based on these studies and can be found at www.littleleague.org. Pitching outside of the league makes tracking some of these things difficult, as many young athletes will play on multiple teams in different leagues who may not follow these guidelines.


The first testing should be a thorough physical exam by a Sports Medicine Fellowship trained Orthopaedic Surgeon. If an ulnar collateral ligament injury is suspected, after some screening x-rays are performed, an MRI scan may be warranted. This is a test that will demonstrate the soft tissues around the elbow.


A trial of non-surgical management is encouraged, especially in the young adolescent athlete. This usually consists of at least 6 weeks of no throwing as we begin physical therapy. There are often many areas of deficiency to address, including motion deficits of the shoulder, pitching mechanics, weakness of the core and kinetic chain (the center of the body (hips, abdominal, gluteal, back) and legs) as well as the shoulder. Once these deficits have been identified and addressed, then a VERY gradual, SUPERVISED throwing program may begin. The patient must remain pain free through this course and progression to be able to return to competition. In the event that this fails, or that the tear is complete on evaluation, surgery may be required if the patient is still planning to play, and to pitch. Surgery is reconstructive, which means the ligament is replaced by a tendon graft connecting the two bones. Often a tendon from the forearm or the opposite hamstring (at the knee) is used. Rehabilitation is long and deliberate and a return to competitive throwing is expected 9-12 months after surgery. Outcomes from surgery reveal a very high rate of return to the same level of competition. However, a very recent report from the American Orthopedic Society for Sports medicine in Major League pitchers shows a trend toward a higher ERA, WHIP (walks and hits per inning pitched), and innings pitched thereafter. Very few, if any, adolescent pitchers requiring this surgery will ever make it to the Major League level. Below are some useful guidelines from USA Baseball. Table1_Baseball Table2_Baseball Table3_Baseball

MRI: Not the Whole Story – By: William P. Rix, MD

Posted on May 30, 2014.

MRI:  Not the Whole Story

William P. Rix, MD

MRI is an imaging tool commonly used by orthopedists in making a diagnosis in patients with musculoskeletal complaints.  It is frequently mentioned in the media when professional athletes are injured:

“Major League Baseball pitcher John Smith’s production has fallen over the past few games. MRI of his sore shoulder reveals no structural damage and rest is indicated.”

“National Football League lineman Jim White’s episodes of low back pain have limited his starts this season. An MRI showed he will need surgery and will be out for the rest of the season”.

The implication of these common references in the sports media is that an MRI offers the definitive answer for musculoskeletal problems. MRI is a state-of-the-art imaging technique that depicts the anatomy of our musculoskeletal system in astonishing detail.  Despite its unquestionable value, however, it can be confusing and in some cases, downright misleading. This is because the abnormality seen on the scan may not be the cause of the patient’s problem. Remarkable as the technology is, it is no substitute for a good history and physical examination.

To illustrate, let’s look at some actual cases:

  • A 50-year-old man was referred to the orthopedist for possible surgery after an MRI revealed a small rotator cuff tear in his shoulder.  The patient told the orthopedist that he had experienced sudden onset of severe shoulder pain without injury in a previously normal shoulder.  His pain had subsided after 2 weeks, but left him with profound shoulder weakness. The physical examination revealed severe wasting of the supraspinatus and infraspinatus muscles, two important components of the rotator cuff. Because rotator cuff patients usually do not present with such extremes on history or examination, the orthopedist suspected something else was going on. Further muscle testing revealed subtle weakness of the Serratus Anterior, a muscle that holds the scapula (wing-bone) tight to the chest wall, a finding inconsistent with a primary diagnosisof rotator cuff tear. Electrical nerve studies confirmed that this man had inflammation of his brachial plexus, the network of nerves that runs from collarbone to armpit and   sends nerves to the shoulder girdle and arm.  Though the exact cause of this condition is unknown, the treatment is non-surgical. This man was instructed in an exercise program and his weakness resolved over the next 12 months. The cuff tear was not addressed because it was an incidental finding on MRI and did not contribute to the man`s symptoms.
  • A 75-year-old woman experienced severe knee pain when she twisted her leg getting up from the toilet. She arrived at her primary care physician’s office using a walker and unable to bear weight on that leg.  A knee x-ray showed no fracture, but an MRI of the knee revealed a torn meniscus (cartilage) and mild-to-moderate arthritis. She was referred to the orthopedist for possible arthroscopic surgery.  During thehistory, the orthopedist noted that the woman was very thin, her diet tended toward “tea and toast” rather than three nutritional meals per day and she smoked, all high risk factors for osteoporosis.  The physical examination revealed the knee was non-tender over the torn cartilage area and there was no effusion (water in the knee).  These negative findings were unusualfor symptoms coming from a torn meniscus as seen on her MRI.  Bending and straightening her knee while sitting (hip stationary) caused no pain, but doing the same maneuver in a supine position (hip free to move) reproduced her severe knee pain.  The orthopedist became concerned about a hip fracture because hip bone and hip joint conditions sometimes refer pain only to the knee rather than the more common areas of groin and buttocks.  An x-ray of her pelvis revealed a non-displaced fragility fracture of the hip, a break that occurs in osteoporotic bone after minor trauma. The danger was that the hip fracture might displace at any time causing pain, blood loss and even death. She underwent same day hip pinning surgery with complete resolution of her pain. She was also counseled on the proper treatment of her osteoporosis. The torn meniscus was not the root cause of this woman`s pain and therefore was ignored.
  • Our last example is a 65-year-old man with a six month history of increasing buttocks pain, right greater than left.  His pain was worse on walking and better with rest.  He had undergone low back (lumbar) surgery 10 years prior and experienced intermittent episodes of backache ever since.  An MRI of his lumbar spine showed lumbar stenosis (narrowing) at the site of the old surgery.  Spine physical therapy had been ineffective in reducing his pain significantly.  He was referred to the orthopedic spine surgeon for possible decompressive surgery at the area of stenosis. The history revealed that the man’s father was “loaded with arthritis” and his brother had undergone both total knee and total hip surgery for debilitating arthritis. The surgeon also noted that the patient, when getting onto the exam table, used his hand to assist in lifting his right leg from the vertical to the horizontal, a move more typical of hip problems than back problems. Physical examination of the hip revealed stiffness, and stressing the hips in rotation reproduced his buttock pain. Dedicated X-rays of his hips revealed bilateral osteoarthritis, right greater than left.  Since both lumbar stenosis and hip arthritis can cause buttocks symptoms, further testing were needed to identify which condition was the primary pain generator. An injection into both hip joints with steroid and Xylocaine completely relieved this man’s pain, thus confirming that his buttocks pain was coming from his hips and not from his low back. This man eventually underwent total hip replacement on both sides, as the steroid`s benefit was only temporary. The coexisting lumbar stenosis was not the root cause of this patient’s problem and was left alone.

In all three cases, the MRI showed a true structural abnormality that could be corrected surgically.  However, one does not operate on an abnormality just because it`s there.  It has to be the cause of the patient`s problem.  The MRI did not tell the physician if the findings seen on film were actually causing the patient’s symptoms. An MRI cannot stand by itself. It must be ordered and interpreted in the context of a proper history and exam. In these patients, the MRI findings were age-related or post-surgical and not contributing to their complaints.

The proper sequence in arriving at the root of a patient’s orthopedic problem is a thorough history, a proper examination and, usually, an x-ray.  If further investigation is needed to come to a specific diagnosis, further testing, including MRI is then employed.

Since the time of Hippocrates, the backbone of delivering good patient care has been the history and physical. It still is.

Every Day Kids Suffer Concussions – What You Need to Know

Posted on May 13, 2014.

Every Day Kids Suffer Concussions – What You Need to Know

By: Daniel P. Bouvier, MD

What are they?

A concussion is an injury to the brain that alters its function, the effects of which are usually temporary. These effects are variable and can include difficulty with concentration, memory, balance, and coordination.


These can range from very subtle, to obvious and severe. Headache, loss of memory, and confusion are often seen. Loss of memory can include events prior to the injury and will often include loss of memory of how the injury occurred.


Things to look for include:

  • Headache/pressure
  • Dizziness
  • Confusion/fogginess/amnesia to event
  • Dazed appearance
  • Delayed response to questions
  • Ear ringing/slurred speech
  • Loss of consciousness
  • Nausea/vomiting

Seizures, altered vision, pupils that don’t appear symmetric, or prolonged loss of consciousness require immediate evaluation


The brain is a very delicate structure encased in a solid container (skull). Anything that causes the brain to knock up against the side of the skull may result in a concussion. A DIRECT BLOW TO THE HEAD IS NOT REQUIRED TO RESULT IN A CONCUSSION, NOR IS DIRECT CONTACT. Rapid deceleration of the head can cause the brain to hit the skull and result in a concussion.

Risk Factors

Participation in collision sports such as lacrosse (in this case) is a risk factor. Another very important risk factor is having had a previous concussion.


On field evaluation includes evaluating consciousness and protecting any neck injury. There are various sideline tools used to assess the athletes symptoms and ability to recall or think. These are brief screening tools for the in-game setting which are usually followed by more comprehensive neurocognitive testing.

There is no routine x-ray or medical test to diagnose concussion. CT SCANS AND MRIs ARE TYPICALLY NORMAL with a concussion. If a patient develops specific neurological symptoms such as prolonged or worsening pain, loss of vision, asymmetric pupils, repeated vomiting or seizures CT scans and/or MRI can tell if there is bleeding on the brain that may be the cause.


1. “When in doubt, keep ‘em out”. The first step is removing the athlete from participation as soon as a concussion is suspected.

2. Rest. This includes rest from both physical and mental activity. This includes all “thinking” activities like reading, video games, TV, etc.

3. Tylenol (acetaminophen) is useful for headaches, but NSAIDs such as Ibuprofen (Motrin, Advil), Aleve, and Aspirin are NOT recommended, as this may increase the risk of bleeding.

4. Progression back to activity begins with mental activity first.

5. Some studies have suggested that gentle exercise that keeps the athlete below their symptom threshold might help decrease the possibility of post concussion syndrome and help both athletes and non-athletes return to activity.

Return to Play

Most athletes will have resolution of symptoms after two weeks and a return of their neurological testing to a baseline (“normal”) in 7-10 days. Internationally accepted return to play criteria includes:

  • The athlete must have no symptoms at rest
  • The athlete must have no symptoms with full mental and physical exertion
  • Balance testing must return to baseline
  • Neurocognitive (brain/thinking) testing must return to baseline

Once an athlete has no symptoms at rest, they can then progress through a guided protocol of rehab to return to play. Each stage takes 24 hrs, so that it takes at least 5 days to progress through the protocol prior to full game participation.



Preventative measures are of paramount importance in high risk sports. Players, Coaches, and parents have a role to play in not only recognition of sports concussions, but in changing the behavior and culture that may result in concussion. Many players, coaches, and parents may feel like aggressive behavior is required in certain sports. These feelings are often heard expounded from the sidelines. Proper technique, age appropriate rules for contact, and sportsmanship can result in decreased incidence of concussions.

Helmets and new helmet technology have been shown to decrease the risk of concussion and newer technologies are promising.

There is lack of conclusive evidence that the use of a mouth guard or specific types of mouth guards reduce the risk of concussion. Mouth guards do, however, reduce the risk of dental trauma which makes them invaluable in that role.


Post Concussion Syndrome is the persistence of any of the following after a concussion: headaches, dizziness, fatigue, irritability, difficulty with concentration and mental tasks, memory impairment, insomnia, and reduced tolerance to stress.   It’s suspected if these symptoms persist more than 1-6 weeks after initial injury.    Athletes who present initially with more symptoms take longer to recover.

Epilepsy: The risk of developing Epilepsy is doubled in the first 5 years post concussion.

Second Impact Syndrome: This is when an athlete sustains 2 successive injuries before recovery of the first is complete. Younger athletes seem especially susceptible to this, which can be a devastating complication leading to rapid brain swelling and death. Second Impact Synrome highlights the importance of restricting athletes from play until they have NO SYMPTOMS.

CTE (Chronic Traumatic Encephalopathy): This is a degenerative condition of the brain that occurs years after recovery. It is the topic of much conversation and research. Early in CTE, patients can have problems with irritability, depression, and poor memory. Later on, it can affect physical movement and speech. (See Junior Seau, Jim McMahon, both former NFL players)


There are multiple resources available for education for players, parents, coaches, and trainers on this topic which include programs for preseason baseline testing for players which is instituted in many local high schools and routinely at the collegiate and professional levels.

NCAA Concussion in Sports www.ncaa.org/health-and-safety/medical-conditions/concussion
Centers for Disease Control and Prevention Heads Up Toolkit for High School Sports www.cdc.gov/concussion/HeadsUp/high_school.html
Centers for Disease Control and Prevention Heads Up Toolkit for Schools www.cdc.gov/concussion/HeadsUp/schools.html
Centers for Disease Control and Prevention Heads Up Toolkit for Physicians www.cdc.gov/concussion/HeadsUp/physicians_tool_kit.html
Computerized neuropsychological tests
ImPACT www.impacttest.com
CogState www.cogstate.com/go/sport
HeadMinder www.headminder.com
U.S. Army Medical Department, Automated Neurocognitive Assessment Metrics (ANAM) www.armymedicine.army.mil/prr/anam.html

**The Journal of Bone and Joint Surgery Current Concepts Review, Vol 94, Issue 17

Another I would add to this is sportslegacy.org, which is an organization headed by Chris Nowinski and Dr. Robert Cantu with cutting edge education and policy on this enormously important matter. There are several links and guides to setting up and maintaining an active concussion surveillance and management program for teams and institutions.